McBurney’s point: 1/3 distance on a line traced superomedially from anterior superior iliac spine to umbilicus. Rovsing sign: palpation of LLQ worsens RLQ pain. Psoas sign: extension of R leg at the hip while pt lying on left side. Obturator sign: pain with internal and external rotation of the thigh at the hip. Adler’s sign: to differentiate appendicitis from tuboovarian pathology in RLQ: find point of maximal tenderness in supine position, then have pt roll onto left side and if pain shifts toward center, its tubo-ovarian.

CT: IV may not be needed. One study with unenhanced CT was 95% sens and 100% spec. A systemic review showed 93% sensitivity. If CT equivocal, 30% still have true appendicitis (Daly, 2005). ACR Appropriateness recommendations leave it up to institutional preference, though give CT without contrast a 7 rating.

Using Samuel’s Pediatric Score (PAS), one study placed children into low, moderate, or high risk. If low, they were discharge with f/u (no appys found). In high risk, all had appy in OR. Moderate risk were either admitted with most have ultrasound. 33 of 119 had positive US, positive OR. 5 with negative US were found later to have appy. Only 13 of the 196 kids had CT scans. (Saucier, 2014). PAS points: Anorexia, Nausea or Vomiting, Migration of pain, Fever > 100.5, Pain with cough, percussion, or hopping (2 points), RLQ tenderness (2 points), WBC > 10, Neutrophils > 75%.